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Perrucci E, Macchia G, Cerrotta A, Andrulli AD, Autorino R, Barcellini A, Campitelli M, Corrao G, Costantini S, De Sanctis V, Di Muzio J, Epifani V, Ferrazza P, Fodor A, Garibaldi E, Laliscia C, Lazzari R, Magri E, Mariucci C, Pace MP, Pappalardi B, Pastorino A, Piccolo F, Scoglio C, Surgo A, Titone F, Tortoreto F, De Felice F, Aristei C. Prevention and management of radiotherapy-related toxicities in gynecological malignancies. Position paper on behalf of AIRO (Italian Association of Radiotherapy and Clinical Oncology). LA RADIOLOGIA MEDICA 2024; 129:1329-1351. [PMID: 39198369 PMCID: PMC11379782 DOI: 10.1007/s11547-024-01844-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/01/2024] [Indexed: 09/01/2024]
Abstract
Multi-modal therapies for gynecological cancers management may determine a wide range of side effects which depend on therapy-related factors and patient characteristics and comorbidities. Curative or adjuvant pelvic radiotherapy is linked with acute and late toxicity due to irradiation of organs at risk, as small and large bowel, rectum, bladder, pelvic bone, vagina and bone marrow. Successful toxicity management varies with its severity, Radiation Centre practice and experience and skills of radiation oncologists. This position paper was designed by the Italian Association of Radiation and Clinical Oncology Gynecology Study Group to provide radiation oncologists with evidence-based strategies to prevent and manage acute and late toxicities and follow-up recommendations for gynecological cancer patients submitted radiotherapy. Six workgroups of radiation oncologists with over 5 years of experience in gynecologic cancers were setup to investigate radiotherapy-related toxicities. For each topic, PubMed database was searched for relevant English language papers from January 2005 to December 2022. Titles and abstracts of results were checked to verify suitability for the document. Reference lists of selected studies and review papers were added if pertinent. Data on incidence, etiopathogenesis, prevention, treatment and follow-up of acute and late side effects for each organ at risk are presented and discussed.
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Affiliation(s)
| | - Gabriella Macchia
- Radiation Oncology Unit, Responsible Research Hospital, Campobasso, Italy
| | - Annamaria Cerrotta
- Radiotherapy Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Rosa Autorino
- UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Maura Campitelli
- UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giulia Corrao
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Sara Costantini
- Radiation Oncology Centre, Santa Maria Hospital, Terni, Italy
| | - Vitaliana De Sanctis
- Radiotherapy Oncology, Department of Medicine, Surgery and Translational Medicine, St. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Jacopo Di Muzio
- Dipartimento Di Oncologia P.O. S. Anna - SS Radioterapia, A.O.U "Città Della Salute E Della Scienza", Turin, Italy
| | - Valeria Epifani
- Radiation Oncology Section, University of Perugia, Perugia, Italy.
| | | | - Andrei Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Garibaldi
- Department of Radiotherapy, Ospedale Regionale Parini-AUSL Valle d'Aosta, Aosta, Italy
| | - Concetta Laliscia
- Department of Translational Medicine, Radiation Oncology Division, University of Pisa, Pisa, Italy
| | - Roberta Lazzari
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Elena Magri
- Department of Radiotherapy, Santa Chiara Hospital, Trento, Italy
| | - Cristina Mariucci
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Maria Paola Pace
- UOC Radioterapia Oncologica, Ospedale Generale Provinciale di Macerata, AST Macerata, Italy
| | - Brigida Pappalardi
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Federica Piccolo
- Radiotherapy Unit, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Claudio Scoglio
- Radiotherapy Unit, Ospedale Maggiore di Trieste, Trieste, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Francesca Titone
- Radiation Oncology Unit, Department of Oncology, "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I, Department of Radiological, Oncological and Pathological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
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Elgendy M, Billey A, Saleem A, Zeeshan B, Dissanayake G, Zergaw M, Nwosu M. A Comprehensive Narrative Review of the Impact of Pelvic Radiotherapy on Pelvic Bone Health: Pathophysiology, Early Diagnosis, and Prevention Strategies. Cureus 2024; 16:e66839. [PMID: 39280418 PMCID: PMC11398843 DOI: 10.7759/cureus.66839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 08/14/2024] [Indexed: 09/18/2024] Open
Abstract
Radiotherapy is a commonly used modality in pelvic malignancies such as prostate, gastrointestinal, or gynecological, either as a primary treatment or an adjuvant post-surgery. Despite its positive impact on the prognosis of these patients, it was found in several studies that it contributes to insufficiency fractures in different sites of the pelvis, more commonly in the sacral ala. This is particularly true for elderly patients. There are several hypotheses on how radiotherapy affects bone health, as it destroys the bone matrix and causes obliterative vasculitis. Several imaging techniques, particularly magnetic resonance imaging (MRI), help detect the radiotherapy-induced fracture and distinguish it from metastases. Some modalities, such as intensity-modulated radiotherapy (IMRT) and brachytherapy, have decreased fracture risk by escaping the adjacent structures to the targeted organ. Pharmacological interventions such as amifostine and desferrioxamine are promising in terms of bone protection, which necessitates further studies to confirm their mechanism of action.
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Affiliation(s)
- Mohamed Elgendy
- Trauma and Orthopedics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Alvin Billey
- Pathology and Laboratory Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Asra Saleem
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bushra Zeeshan
- Dermatology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Gayanthi Dissanayake
- Internal Medicine and Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Meaza Zergaw
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Marcellina Nwosu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Lau B, Wu YF, Cui S, Fu J, Jackson S, Pham D, Dubrowski P, Eswarappa S, Skinner L, Shirato H, Taguchi H, Gensheimer MF, Gee H, Chin AL, Diehn M, Loo BW, Moiseenko V, Vitzthum LK. Chest wall pain after single-fraction thoracic stereotactic ablative Radiotherapy: Dosimetric analysis from the iSABR trial. Radiother Oncol 2024; 196:110317. [PMID: 38679202 DOI: 10.1016/j.radonc.2024.110317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND PURPOSE Concerns over chest wall toxicity has led to debates on treating tumors adjacent to the chest wall with single-fraction stereotactic ablative radiotherapy (SABR). We performed a secondary analysis of patients treated on the prospective iSABR trial to determine the incidence and grade of chest wall pain and modeled dose-response to guide radiation planning and estimate risk. MATERIALS AND METHODS This analysis included 99 tumors in 92 patients that were treated with 25 Gy in one fraction on the iSABR trial which individualized dose by tumor size and location. Toxicity events were prospectively collected and graded based on the CTCAE version 4. Dose-response modeling was performed using a logistic model with maximum likelihood method utilized for parameter fitting. RESULTS There were 22 grade 1 or higher chest wall pain events, including five grade 2 events and zero grade 3 or higher events. The volume receiving at least 11 Gy (V11Gy) and the minimum dose to the hottest 2 cc (D2cc) were most highly correlated with toxicity. When dichotomized by an estimated incidence of ≥ 20 % toxicity, the D2cc > 17 Gy (36.6 % vs. 3.7 %, p < 0.01) and V11Gy > 28 cc (40.0 % vs. 8.1 %, p < 0.01) constraints were predictive of chest wall pain, including among a subset of patients with tumors abutting or adjacent to the chest wall. CONCLUSION For small, peripheral tumors, single-fraction SABR is associated with modest rates of low-grade chest wall pain. Proximity to the chest wall may not contraindicate single fractionation when using highly conformal, image-guided techniques with sharp dose gradients.
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Affiliation(s)
- Brianna Lau
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yufan F Wu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sunan Cui
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Jie Fu
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Scott Jackson
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel Pham
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Piotr Dubrowski
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shaila Eswarappa
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lawrie Skinner
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Harriet Gee
- Department of Radiation Oncology, Westmead Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of San Diego School of Medicine, San Diego, CA, USA
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA.
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Haque M, Hossen MS. Insights into pelvic insufficiency fracture following pelvic radiotherapy for cervical cancer: a comparative review. BMC Womens Health 2024; 24:306. [PMID: 38783273 PMCID: PMC11112889 DOI: 10.1186/s12905-024-03099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/16/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Radiotherapy (RT)-induced pelvic insufficiency fractures (PIF) are prevalent in patients with cervical cancer. Inconclusive studies on PIF after cervical irradiation create uncertainty. This review examined PIF after RT in cervical patients, including its pathobiology, likely locations of fractures, incidence, clinical symptoms, and predisposing factors. We further discussed study limitations and therapeutic possibilities of PIF. METHODS The following online resources were searched for relevant articles: Google Scholar and PubMed. The keywords 'pelvic insufficiency fractures', 'cervical carcinoma' and 'cervical cancer', as well as 'chemoradiotherapy', 'chemoradiation', and 'radiotherapy', were some of the terms that were used during the search. RESULTS Patients with PIF report pelvic pain after radiation treatment for cervical cancer; the incidence of PIF ranges from 1.7 to 45.2%. Evidence also supports that among all patients treated with pelvic radiation, those who experienced pelvic insufficiency fractures invariably had at least one sacral fracture, making it the most frequently fractured bone in the body. Menopausal status, weight, BMI, age, and treatments and diagnosis modalities can influence PIF during radiotherapy. CONCLUSIONS In conclusion, our comparative review of the literature highlights significant heterogeneity in various aspects of PIF following radiation for patients with cervical cancer. This diversity encompasses prevalence rates, associated risk factors, symptoms, severity, diagnosis methods, preventive interventions, and follow-up periods. Such diversity underscores the complexity of PIF in this population and emphasizes the critical need for further research to elucidate optimal management strategies and improve patient outcomes.
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Affiliation(s)
- Munima Haque
- Biotechnology Program, Department of Mathematics and Natural Sciences (MNS), School of Data and Sciences (SDS), BRAC University, Kha-224, Merul Badda, Dhaka, 1212, Bangladesh.
| | - Md Sakib Hossen
- Department of Biochemistry and Molecular Biology, Primeasia University, Banani, Dhaka, 1213, Bangladesh
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Malikova H, Nadova K, Reginacova K, Kremenova K, Rob L. Radiation-Related Fractures after Radical Radiotherapy for Cervical and Endometrial Cancers: Are There Any Differences? Diagnostics (Basel) 2024; 14:810. [PMID: 38667456 PMCID: PMC11049002 DOI: 10.3390/diagnostics14080810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
In this study, we reviewed CT/MRI scans and studied the rates of radiation-related fractures in subjects treated for cervical cancer (CC, 63 subjects) by radical radiotherapy (RT) and in subjects treated for endometrial cancer (EC, 64 subjects) by radical surgery and RT. The differences between bone density measured in L1 on pretreatment CT, age and body mass index (BMI) were evaluated. Despite significant differences in RT total dose, age, BMI, etc., between both groups, the rate of radiation-related fractures was similar: 28.6% of CC versus 26.6% of EC subjects. CC subjects with fractures were significantly older (62.4 ± 10.1 vs. 49.0 ± 12.4 years; p < 0.001), and their bone densities were significantly lower (106.3 ± 40.0 vs. 168.2 ± 49.5 HU; p < 0.001); no difference in BMI was found. EC subjects with fractures were without significant difference in age but had significantly lower bone densities (103.8 ± 29.0 vs. 133.8 ± 42.3 HU; p = 0.009) and BMIs (26.1 ± 4.9 vs. 31.8 ± 6.9 kg/m2; p = 0.003). Bone density strongly correlated with age (r = -0.755) only in CC subjects. Subjects with fractures from both groups had similarly low bone densities (106.3 ± 40.0 vs. 103.8 ± 29.0 HU; p = 0.829); however, no correlation between bone density and BMI was found. The rate of radiation-related fractures in both groups was clearly associated only with low pretreatment bone density, reflecting osteoporosis.
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Affiliation(s)
- Hana Malikova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (K.N.); (K.K.)
- Institute of Anatomy, Second Faculty of Medicine, Charles University, 11000 Prague, Czech Republic
| | - Katarina Nadova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (K.N.); (K.K.)
- Institute of Anatomy, Second Faculty of Medicine, Charles University, 11000 Prague, Czech Republic
| | - Klaudia Reginacova
- Department of Oncology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic;
| | - Karin Kremenova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic; (K.N.); (K.K.)
| | - Lukas Rob
- Department of Obstetrics and Gynaecology, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 11000 Prague, Czech Republic;
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Güler T, Yurdakul FG, Karasimav Ö, Kılıç Z, Yaşar E, Bodur H. Radiation-induced lumbosacral plexopathy and pelvic insufficiency fracture: A case report of unique coexistence of complications after radiotherapy for prostate cancer. Jt Dis Relat Surg 2024; 35:455-461. [PMID: 38727129 PMCID: PMC11128954 DOI: 10.52312/jdrs.2024.1551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/27/2024] [Indexed: 05/29/2024] Open
Abstract
Case reports of plexopathy after prostate cancer are usually neoplastic. Radiation-induced lumbosacral plexopathy and insufficiency fractures have clinical significance due to the need to differentiate them from tumoral invasions, metastases, and spinal pathologies. Certain nuances, including clinical presentation and screening methods, help distinguish radiation-induced plexopathy from tumoral plexopathy. This case report highlights the coexistence of these two rare clinical conditions. Herein, we present a 78-year-old male with a history of radiotherapy for prostate cancer who developed right foot drop, severe lower back and right groin pain, difficulty in standing up and walking, and tingling in both legs over the past month during remission. The diagnosis of lumbosacral plexopathy and pelvic insufficiency fracture was made based on magnetic resonance imaging, positron emission tomography, and electroneuromyography. The patient received conservative symptomatic treatment and was discharged with the use of a cane for mobility. Radiation-induced lumbosacral plexopathy following prostate cancer should be kept in mind in patients with neurological disorders of the lower limbs. Pelvic insufficiency fracture should also be considered if the pain does not correspond to the clinical findings of plexopathy. These two pathologies, which can be challenging to diagnose, may require surgical or complex management approaches. However, in this patient, conservative therapies led to an improvement in quality of life and a reduction in the burden of illness.
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Affiliation(s)
- Tuba Güler
- Ankara Bilkent Şehir Hastanesi, Fiziksel Tıp ve Rehabilitasyon Kliniği, 06800 Çankaya, Ankara, Türkiye.
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Lee SW, Kim A, Lee SJ, Kim SH, Lee JH. Intensity-Modulated Radiation Therapy for Uterine Cervical Cancer to Reduce Toxicity and Enhance Efficacy - an Option or a Must?: A Narrative Review. Cancer Res Treat 2024; 56:1-17. [PMID: 37654111 PMCID: PMC10789959 DOI: 10.4143/crt.2023.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023] Open
Abstract
Radiotherapy (RT) is a fundamental modality in treatment of cervical cancer. With advancement of technology, conventional RT used for external beam radiotherapy (EBRT) for over half a century has been rapidly replaced with intensity-modulated radiation therapy (IMRT) especially during the last decade. This newer technique is able to differentiate the intensity of radiation within the same field, thus reduces the inevitable exposure of radiation to normal organs and enables better dose delivery to tumors. Recently, the American Society for Radiation Oncology has released a guideline for RT in cervical cancer. Although a section of the guideline recommends IMRT for the purpose of toxicity reduction, a thorough review of the literature is necessary to understand the current status of IMRT in cervical cancer. This narrative review updates the recent high-level evidences regarding the efficacy and toxicity of IMRT and provides a better understanding of the most innovative techniques currently available for EBRT enabled by IMRT.
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Affiliation(s)
- Sea-Won Lee
- Department of Radiation Oncology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Aeran Kim
- Department of Biomedicine & Health Sciences, The Catholic University of Korea, Seoul, Korea
| | - Sung Jong Lee
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Hwan Kim
- Department of Radiation Oncology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Vesa V, Jaana M, Ia K, Anu C, Heikki M, Raija R, Annika Å, Eetu H. Short-course preoperative radiotherapy increases pelvic fracture risk in rectal cancer. Clin Transl Radiat Oncol 2023; 42:100656. [PMID: 37457020 PMCID: PMC10339188 DOI: 10.1016/j.ctro.2023.100656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/10/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Pelvic insufficiency fractures (PIFs) are adverse events associated with chemoradiotherapy (CRT) administered preoperatively in rectal cancer, with incidences of 0-33.6% reported in the literature. Data on PIFs after 5 × 5 Gy fractionated short-course radiotherapy (SCRT) using highly conformal radiotherapy techniques such as volumetric modulated arc therapy (VMAT) is limited. Methods The Turku University Hospital colorectal cancer database was searched for patients operated on for stage I-III rectal cancer during the years 2014-2018. The hospital's routine follow-up includes a 2-year computed tomography (CT) scan, which was systemically re-evaluated to detect PIFs. Only radiotherapy delivered using VMAT and image-guided approaches was included. Baseline demographics, tumor data, and dose-volume data were collected to identify risk factors for PIFs. Results Median time to CT scan was 24 months. Among the 164 patients analyzed, the 2-year PIF incidence was 22.2% for SCRT (n = 12/54, OR 9.1 (CI95% 1.9-42.9), p = 0.004), 9.1% for CRT (n = 4/44, OR 3.2 (CI95% 0.6-18.3), p = 0.13) and 3.0% (n = 2/66, reference) for those operated on without radiotherapy. The PIF incidence was not explained by differences in dose-volume data in either the SCRT or CRT groups. Fracture risk was higher in women, up to 50% after SCRT. Conclusions Every fifth patient treated with SCRT and rectal surgery presented with a PIF. Critical bony structures to be avoided during radiotherapy contouring could not be identified. Clinicians, especially those involved with the follow-up of rectal cancer, should be aware of this potentially debilitating and surprisingly common adverse event.
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Affiliation(s)
- Väliaho Vesa
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Mäkitalo Jaana
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
- Department of Medical Physics, Turku University Hospital, Hämeentie 11, Turku 20521, Finland
| | - Kohonen Ia
- Medicity Research Laboratory, University of Turku, Tykistökatu 6A, Turku 20520, Finland
- Medical Imaging Centre of Southwest Finland, Turku University Hospital, Hämeentie 11, Turku 20521, Finland
| | - Carpelan Anu
- Department of Digestive Surgery, Turku University Hospital and University of Turku, Kiinamyllynkatu 4–8, Turku 20521, Finland
| | - Minn Heikki
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Ristamäki Raija
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Ålgars Annika
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
| | - Heervä Eetu
- Department of Oncology, Turku University Hospital and University of Turku, Hämeentie 11, Turku 20521, Finland
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Duranson A, Thevenet V, Guyon F, Babin G, Lebreton C, Renaud T, Gaillard AL, Dupuy Q, Bouleftour W, Magne N, Petit A. Pelvic insufficiency fractures after intensity modulated radiation therapy combined with chemotherapy for cervix carcinoma: Incidence and impact of bone mineral density. Clin Transl Radiat Oncol 2023; 41:100650. [PMID: 37441540 PMCID: PMC10334122 DOI: 10.1016/j.ctro.2023.100650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/15/2023] [Accepted: 06/04/2023] [Indexed: 07/15/2023] Open
Abstract
Background and Purpose The aim of this study was to evaluate the incidence and predictive factors of Pelvic Insufficiency Fractures (PIFs) occurring after Intensity Modulated Radiation Therapy (IMRT) combined with chemotherapy for locally advanced cervical cancer (CC). Material and methods Medical records of patients receiving radio-chemotherapy with IMRT between 2010 and 2020 for advanced CC were reviewed. PIFs were detected during follow-up on pelvic Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). The cumulative incidence rate of PIFs and its confidence interval were calculated at 2 and 5 years of follow-up. Pre-therapeutic Bone Mineral Density (BMD) (g/cm3) was evaluated on CT simulation for sacrum and the fourth lumbar (L4) vertebrae. Sacrum dosimetric parameters (V30Gy, V40Gy, D50%, Dmean) were analyzed. Results 136 patients were included. The median follow-up was 4.4 years. Median dose of D50% and V40Gy sacrum were 35.2 Gy (20.6-46.4) and 32.2% (7.2-73.4) respectively. The 2-year and 5-year cumulative incidence rates were 15.7% (95% CI: 9.88-22.71) and 22% (95% CI: 14.58-30.45) respectively. Median time interval between RT completion and PIFs' detection was 11.5 months (IQR: 7.4-22.3). Univariate analysis showed that older age (p < 0.01), postmenopausal status at baseline (p < 0.01), and lower sacral and spinal BMD at baseline (respectively p < 0.001 and p < 0.01) were significantly associated to all sites of PIFs, and lower sacral BMD with sacral fractures (p < 0.001). Conclusion Post-IMRT PIFs were detected in 18.4% of patients with locally advanced CC. Individual predisposing factors as older age, postmenopausal status, decreased bone density on the CT simulation were mainly predictive.
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Affiliation(s)
- Agathe Duranson
- Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Vincent Thevenet
- Department of Statistics, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Frédéric Guyon
- Department of Surgery, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Guillaume Babin
- Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Coriolan Lebreton
- Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Tiphaine Renaud
- Department of Medical Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Anne-Lise Gaillard
- Department of Diagnostic Radiology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Quentin Dupuy
- Department of Medical Physics, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
| | - Wafa Bouleftour
- Department of Medical Oncology, North Hospital, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Nicolas Magne
- Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
- Cellular and Molecular Radiobiology Laboratory, Lyon-Sud Medical School, Unité Mixte de Recherche CNRS5822/IP2I, University of Lyon, Lyon, France
| | - Adeline Petit
- Department of Radiation Oncology, Institut Bergonié, Comprehensive Cancer Center, Bordeaux, France
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10
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Li Y, Zhou Z, Xu S, Jiang J, Xiao J. Review of the Pathogenesis, Diagnosis, and Management of Osteoradionecrosis of the Femoral Head. Med Sci Monit 2023; 29:e940264. [PMID: 37310931 PMCID: PMC10276533 DOI: 10.12659/msm.940264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/13/2023] [Indexed: 06/15/2023] Open
Abstract
Osteoradionecrosis (ORN) of the femoral head is an important issue for orthopedists and radiologists in clinical practice. With the rapid development of technological advances in radiation therapy and the improvement in cancer survival rates, the incidence of ORN is rising, and there is an unmet need for basic and clinical research. The pathogenesis of ORN is complex, and includes vascular injury, mesenchymal stem cell injury, bone loss, reactive oxygen species, radiation-induced fibrosis, and cell senescence. The diagnosis of ORN is challenging and requires multiple considerations, including exposure to ionizing radiation, clinical manifestations, and findings on physical examination and imaging. Differential diagnosis is essential, as clinical symptoms of ORN of the femoral head can resemble many other hip conditions. Hyperbaric oxygen therapy, total hip arthroplasty, and Girdlestone resection arthroplasty are effective treatments, each with their own advantages and disadvantages. The literature on ORN of the femoral head is incomplete and there is no criterion standard or clear consensus on management. Clinicians should gain a better and more comprehensive understanding on this disease to facilitate its early and better prevention, diagnosis, and treatment. This article aims to review the pathogenesis, diagnosis, and management of osteoradionecrosis of the femoral head.
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Affiliation(s)
- Yang Li
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
| | - Zhongsheng Zhou
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
| | - Shenghao Xu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
| | - Jinlan Jiang
- Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
| | - Jianlin Xiao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin, PR China
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11
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Internal fixation of radiation-induced fragility fractures of the pelvis: a case series. Arch Orthop Trauma Surg 2023; 143:865-871. [PMID: 35107637 DOI: 10.1007/s00402-022-04358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/14/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE III, retrospective study.
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12
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Li J, Chen X, Ren L, Chen X, Wu T, Wang Y, Ren X, Cheng B, Xia J. Type H vessel/platelet-derived growth factor receptor β + perivascular cell disintegration is involved in vascular injury and bone loss in radiation-induced bone damage. Cell Prolif 2023:e13406. [PMID: 36694343 DOI: 10.1111/cpr.13406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/26/2023] Open
Abstract
Collapse of the microvascular system is a prerequisite for radiation-induced bone loss. Since type H vessels, a specific bone vessel subtype surrounded by platelet-derived growth factor receptor β+ (PDGFRβ+ ) perivascular cells (PVCs), has been recently identified to couple angiogenesis and osteogenesis, we hypothesize that type H vessel injury initiates PDGFRβ+ PVC dysfunction, which contributes to the abnormal angiogenesis and osteogenesis after irradiation. In this study, we found that radiation led to the decrease of both type H endothelial cell (EC) and PDGFRβ+ PVC numbers. Remarkably, results from lineage tracing showed that PDGFRβ+ PVCs detached from microvessels and converted the lineage commitment from osteoblasts to adipocytes, leading to vascular injury and bone loss after irradiation. These phenotype transitions above were further verified to be associated with the decrease in hypoxia-inducible factor-1α (HIF-1α)/PDGF-BB/PDGFRβ signalling between type H ECs and PDGFRβ+ PVCs. Pharmacological blockade of HIF-1α/PDGF-BB/PDGFRβ signalling induced a phenotype similar to radiation-induced bone damage, while the rescue of this signalling significantly alleviated radiation-induced bone injury. Our findings show that the decrease in HIF-1α/PDGF-BB/PDGFRβ signalling between type H ECs and PDGFRβ+ PVCs after irradiation affects the homeostasis of EC-PVC coupling and plays a part in vascular damage and bone loss, which has broad implications for effective translational therapies.
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Affiliation(s)
- Jiayan Li
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Xiaodan Chen
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Lin Ren
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Xijuan Chen
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Tong Wu
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Yun Wang
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Xianyue Ren
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Bin Cheng
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Juan Xia
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, China.,Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
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13
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Nelson RA, Blakely AM, Larson JC, Chlebowski RT, Chen YJ, Cauley JA, Shadyab AH, Lai LL. Long-term pelvic fracture and overall mortality risk after pelvic cancer and pelvic radiation. J Natl Cancer Inst 2023; 115:104-111. [PMID: 36305666 PMCID: PMC9830483 DOI: 10.1093/jnci/djac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/03/2022] [Accepted: 09/29/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The association of pelvic radiation with pelvic fracture risk has not been examined in prospective cohort settings with comprehensive fracture risk assessment, cancer-free comparison populations, and long-term follow-up. Our objective is to better characterize pelvic fracture and overall mortality risks in postmenopausal women participating in the Women's Health Initiative. METHODS A total of 135 743 Women's Health Initiative participants aged 50 to 79 years enrolled from 40 US clinical centers from 1993 to 1998 who had entry Fracture Risk Assessment Tool scores were eligible. Outcomes included pelvic cancer diagnosis, pelvic fracture occurrence, and mortality. Cox proportional hazards regression models were used to examine associations of pelvic cancer and pelvic radiation with pelvic fracture and mortality risk. RESULTS After 17.7 years (median) follow-up, 4451 pelvic cancers, 10 139 pelvic fractures, and 33 040 deaths occurred. In multivariable analyses, women with incident pelvic cancer, compared with women who remained pelvic cancer free, had higher pelvic fracture risk (hazard ratio [HR] = 1.26, 95% confidence interval [CI] = 1.11 to 1.43) and higher overall mortality risk (HR = 2.91, 95% CI = 2.77 to 3.05). Women with pelvic cancer treated with pelvic radiation, compared with women with pelvic cancer not treated with pelvic radiation, had higher pelvic fracture risk (HR = 1.98, 95% CI = 1.41 to 2.78) and higher overall mortality after pelvic cancer (HR = 1.32, 95% CI = 1.15 to 1.52). CONCLUSIONS Postmenopausal women with pelvic cancer, especially those receiving pelvic radiation, are at higher pelvic fracture risk and higher overall mortality risk. As therapeutic advances have reduced cancer mortality, attention to and interventions for pelvic fracture prevention may be important in pelvic cancer survivors.
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Affiliation(s)
- Rebecca A Nelson
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Andrew M Blakely
- Surgical Oncology Program, National Cancer Institute, Bethesda, MD, USA
| | | | - Rowan T Chlebowski
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Yi-Jen Chen
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Lily L Lai
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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14
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Jensenius KC, Ginnerup PB, Jeppe K, Cecilie L, Lycke K, Garm KL. Pelvic insufficiency fractures and bone pain after radiotherapy for anal cancer -Relation to pelvic bone dose volume parameters. Adv Radiat Oncol 2022; 8:101110. [DOI: 10.1016/j.adro.2022.101110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
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15
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Abdelkarem OAI, Choudhury A, Burnet NG, Summersgill HR, West CML. Effect of Race and Ethnicity on Risk of Radiotherapy Toxicity and Implications for Radiogenomics. Clin Oncol (R Coll Radiol) 2022; 34:653-669. [PMID: 35431121 DOI: 10.1016/j.clon.2022.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/21/2022] [Accepted: 03/16/2022] [Indexed: 11/03/2022]
Abstract
AIMS Patient factors affect the risk of radiotherapy toxicity, but many are poorly defined. Studies have shown that race affects cancer incidence, survival, drug response, molecular pathways and epigenetics. Effects on radiosensitivity and radiotherapy toxicity are not well studied. The aim of the present study was to identify the effects of race and ethnicity on the risk of radiotherapy toxicity. MATERIALS AND METHODS A systematic review was carried out of PubMed, Ovid Medline and Ovid Embase with no year limit. PRISMA 2020 guidelines were followed. Two independent assessors reviewed papers. RESULTS Of 607 papers screened, 46 fulfilled the inclusion criteria. Papers were published between 1996 and 2021 and involved 30-28,354 individuals (median 433). Most involved patients with prostate (33%), breast (26%) and lung (9%) cancer. Both early and late toxicities were studied. Some studies reported a higher risk of toxicity in White men with prostate cancer compared with other races and ethnicities. For breast cancer patients, some reported an increased risk of toxicity in White women compared with other race and ethnic groups. In general, it was difficult to draw conclusions due to insufficient reporting and analysis of race and ethnicity in published literature. CONCLUSIONS Reporting of race and ethnicity in radiotherapy studies must be harmonised and improved and frameworks are needed to improve the quality of reporting. Further research is needed to understand how ancestral heritage might affect radiosensitivity and risk of radiotherapy toxicity.
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Affiliation(s)
- O A I Abdelkarem
- Chemical Pathology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt; Translational Radiobiology Group, Division of Cancer Sciences, Manchester Academic Health Science Centre, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - A Choudhury
- Proton Beam Therapy Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - N G Burnet
- Proton Beam Therapy Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - H R Summersgill
- Translational Radiobiology Group, Division of Cancer Sciences, Manchester Academic Health Science Centre, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - C M L West
- Translational Radiobiology Group, Division of Cancer Sciences, Manchester Academic Health Science Centre, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK.
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16
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Serial bone density changes in women undergoing pelvic (chemo) radiation: Results from PARCER trial. Int J Radiat Oncol Biol Phys 2022; 114:463-471. [PMID: 35870710 DOI: 10.1016/j.ijrobp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/23/2022] [Accepted: 07/03/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Pelvic irradiation leads to substantial dose to the pelvic girdle. However, bone density loss as a function of radiotherapy (RT) dose and time has not been investigated. This study was undertaken to evaluate such a dose-response relationship. METHODS AND MATERIALS Women undergoing pelvic radiotherapy for cervix cancer within a phase III trial were included. The study necessitated 2 CT imaging sets acquired atleast 12 months apart in patients with no evidence of relapse. All images were transferred to the treatment planning system to determine radiation dose and Hounsfield Unit (HU). Across the entire lumbopelvic region (Lumbar 1-5 (L1-5) vertebra, pubic symphysis, femur, acetabulum, greater trochanter, and anterior-superior iliac spine) multiple regions were defined to measure RT dose and HU. Bone health was categorized as normal if HU>130, osteopenic at 110-130 HU and osteoporotic <110HU at baseline and follow up. Univariate analysis was performed to test impact of various factors on HU. Further interaction between radiotherapy dose, time and HU was assessed using linear mixed model. RESULTS Overall, 132/300 patients were eligible. The median age was 49 (42-56) years. With a prescription dose of 50Gy, L1-2 vertebra received median dose of 1.2Gy and 4Gy respectively, L3-5 received 10-50 Gy. At 24 months, median HU loss at L4-5 was 45 HU (IQR: 34-77HU). Out of the 132 patients, at baseline 96% had normal bone health. However, at the last follow up 3% of patients had normal bone health and 12% developed osteopenia and 85% developed osteoporosis (p-value <0.001). No patient or treatment related factors predicted for HU loss on univariate analysis. HU loss >60-70 was observed at >45 Gy at L5 vertebrae (60-70 HU, p<0.02) and >15 Gy at L4 vertebra (33HU and p value 0.04). CONCLUSIONS Dose-response relationship is observed between radiation dose and bone mineral density loss. Prospective studies are needed to corroborate these observations and design future interventions.
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17
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Huang JG, Zhang ZY, Li L, Liu GB, Li X. Multi-slice spiral computed tomography in diagnosing unstable pelvic fractures in elderly and effect of less invasive stabilization. World J Clin Cases 2022; 10:4470-4479. [PMID: 35663060 PMCID: PMC9125281 DOI: 10.12998/wjcc.v10.i14.4470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/17/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Older people are more likely to experience pelvic fractures than younger people. Multi-slice spiral computed tomography (CT) uses three-dimensional (3D) reconstruction technology to generate 3D images that can clearly demonstrate the 3D space of fractures and detect fractures at a higher rate. AIM To investigate the clinical value of multi-slice spiral CT 3D reconstruction in the diagnosis of unstable pelvic fractures in the elderly as well as the effect of less invasive stabilization. METHODS A total of 86 patients with unstable pelvic fractures treated between March 2016 and March 2019 underwent femoral supracondylar bone traction before surgery. Pelvic radiography and multi-row spiral CT were performed successively once the patient's vital signs and hemodynamic indices were stable. Secondary processing of the original data was performed to obtain 3D reconstruction images and determine the vertical displacement of the pelvis. After basic or complete reduction, minimally invasive internal fixation using hollow lag screws was performed. The detection rates of fracture location and classification by X-ray and CT reconstruction were compared. Patients were divided into two groups according to the presence or absence of preoperative 3D reconstruction to compare postoperative reduction, wound healing time, fracture healing time, hospitalization time, visual analog scale (VAS) score, poor internal fixation, and functional recovery. RESULTS The diagnostic coincidence rates of X-rays for pubic symphysis, ilium wing, sacroiliac periarticular, and sacral fractures were lower than those of CT reconstruction. The coincidence rate of CT reconstruction in the clinical classification of pelvic fractures was 100%, whereas 11 cases were misdiagnosed by X-ray; the total coincidence rate was 87.21%. The total excellent and good rates of postoperative reduction were significantly higher in the study group than in the control group (P < 0.05). The wound healing, fracture healing, and hospitalization times were significantly shorter in the study group than in the control group (P < 0.05). The VAS scores decreased in both groups postoperatively and were lower in the study group than in the control group (P < 0.05). The total incidence of poor postoperative internal fixation was significantly lower in the study group than in the control group (P < 0.05). The overall rate of postoperative functional recovery was significantly higher in the study group than in the control group (P < 0.05). CONCLUSION Multi-slice spiral CT has high guiding significance for the diagnosis, classification, and treatment of unstable pelvic fractures in the elderly. Preoperative 3D reconstruction can effectively shorten the operation time and promote fracture healing, while minimally invasive internal fixation can effectively reduce pain and promote functional recovery of fracture sites, making it worthy of clinical application.
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Affiliation(s)
- Jian-Guo Huang
- Department of Orthopedics, Sanya Hospital of Traditional Chinese Medicine, Sanya 572000, Hainan Province, China
| | - Zhi-Yuan Zhang
- Department of Orthopedics, Sanya Hospital of Traditional Chinese Medicine, Sanya 572000, Hainan Province, China
| | - Liang Li
- Department of Orthopedics, Xi’an Honghui Hospital, Xi’an 710024, Shaanxi Province, China
| | - Guang-Bao Liu
- Department of Radiology, Sanya Hospital of Traditional Chinese Medicine, Sanya 572000, Hainan Province, China
| | - Xiong Li
- Department of Traumatic Orthopedics Sports Medicine, Yan’an Hospital of Traditional Chinese Medicine, Yan’an 716000, Shaanxi Province, China
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18
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Williamson CW, Sirák I, Xu R, Portelance L, Wei L, Tarnawski R, Mahantshetty U, Heide ES, Yashar CM, McHale MT, Bosch W, Lowenstein J, Saenz CC, Plaxe S, Eskander R, Einck J, Mundt AJ, Mayadev J, Mell LK. Positron Emission Tomography-Guided Bone Marrow-Sparing Radiation Therapy for Locoregionally Advanced Cervix Cancer: Final Results From the INTERTECC Phase II/III Trial. Int J Radiat Oncol Biol Phys 2022; 112:169-178. [PMID: 34419564 PMCID: PMC8688221 DOI: 10.1016/j.ijrobp.2021.08.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE To test effects of positron emission tomography (PET)-based bone marrow-sparing (BMS) image-guided intensity modulated radiation therapy (IG-IMRT) on efficacy and toxicity for patients with locoregionally advanced cervical cancer. METHODS AND MATERIALS In an international phase II/III trial, patients with stage IB-IVA cervical carcinoma were treated with either PET-based BMS-IG-IMRT (PET-BMS-IMRT group) or standard image-guided IMRT (IMRT group), with concurrent cisplatin (40 mg/m2 weekly), followed by brachytherapy. The phase II component nonrandomly assigned patients to PET-BMS-IMRT or standard IMRT. The phase III trial randomized patients to PET-BMS-IMRT versus IMRT, with a primary endpoint of progression-free survival (PFS) but was closed early for futility. Phase III patients were analyzed separately and in combination with phase II patients, comparing acute hematologic toxicity, cisplatin delivery, PFS, overall survival (OS), and patterns of failure. In a post-hoc exploratory analysis, we investigated the association between pretreatment absolute lymphocyte count (ALC) and OS. RESULTS In total, 101 patients were enrolled on the phase II/III trial, including 29 enrolled in phase III (PET-BMS-IMRT group: 16; IMRT group: 13) before early closure. Median follow-up was 33 months for phase III patients and 39 months for all patients. PFS and OS at 5 years for all patients were 73.6% (95% confidence interval [CI], 64.9%-84.3%) and 84% (95% CI, 76%-92.9%]), respectively. There were no differences in number of cisplatin cycles, OS, PFS, or patterns of failure between groups for the combined cohort. The incidence of acute grade ≥ 3 neutropenia was significantly lower in the PET-BMS-IMRT group compared with IMRT for randomized patients (19% vs 54%, χ2P = .048) and in the combined cohort (13% vs 35%, χ2P = .01). Patients with pretreatment ALC ≤ 1.5 k/µL had nonsignificantly worse OS on multivariable analysis (HR 2.85; 95% CI, 0.94-8.62; adjusted P = .216), compared with patients with ALC > 1.5 k/µL. There was no difference in posttreatment ALC by treatment group. CONCLUSIONS PET-BMS-IMRT significantly reduced acute grade ≥3 neutropenia, but not treatment-related lymphopenia, compared with standard IMRT. We found no evidence that PET-BMS-IMRT affected chemotherapy delivery or long-term outcomes, and weak evidence of an association between pretreatment ALC and OS.
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Affiliation(s)
- Casey W Williamson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Igor Sirák
- Department of Oncology and Radiotherapy, University Hospital, Hradec Kralove, Czech Republic
| | - Ronghui Xu
- University of California San Diego, La Jolla, California
| | | | | | - Rafal Tarnawski
- Marie Sklodowska Cancer Center and Institute of Oncology, Gliwice, Poland
| | | | | | - Catheryn M Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | | | - Walter Bosch
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | | | - Cheryl C Saenz
- University of California San Diego, La Jolla, California
| | - Steve Plaxe
- University of California San Diego, La Jolla, California
| | - Ramez Eskander
- University of California San Diego, La Jolla, California
| | - John Einck
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Jyoti Mayadev
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California; La Jolla Center for Precision Radiation Medicine, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California; La Jolla Center for Precision Radiation Medicine, La Jolla, California.
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19
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Mell LK. Trials and tribulations of bone marrow sparing radiotherapy for cervical cancer. Radiother Oncol 2021; 167:78-80. [PMID: 34896460 DOI: 10.1016/j.radonc.2021.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, United States.
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20
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Haas S, Mikkelsen AH, Kronborg C, Oggesen BT, Faaborg PM, Serup-Hansen E, Spindler KLG, Christensen P. Management of late adverse effects after chemoradiation for anal cancer. Acta Oncol 2021; 60:1688-1701. [PMID: 34845967 DOI: 10.1080/0284186x.2021.1983208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects. MATERIALS AND METHODS Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations. SCIENTIFIC EVIDENCE Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available. CONCLUSION Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.
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Affiliation(s)
- Susanne Haas
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
| | | | - Camilla Kronborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Pia Moeller Faaborg
- Department of Surgery, Vejle Hospital, Danish Colorectal Cancer Centre South, Vejle, Denmark
| | | | | | - Peter Christensen
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
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Yusufaly TI, Meyers SM, Mell LK, Moore KL. Knowledge-Based Planning for Intact Cervical Cancer. Semin Radiat Oncol 2021; 30:328-339. [PMID: 32828388 DOI: 10.1016/j.semradonc.2020.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cervical cancer radiotherapy is often complicated by significant variability in the quality and consistency of treatment plans. Knowledge-based planning (KBP), which utilizes prior patient data to correlated achievable optimal dosimetry with patient-specific anatomy, has demonstrated promise as a quality control tool for controlling this variability, with consequences for patient outcomes, as well as for the reliability of data from multi-institutional clinical trials. In this article we highlight the application of KBP-based quality control to cervical cancer radiotherapy. We discuss the potential impact of KBP on multi-institutional clinical trials to standardize cervical cancer treatment planning across diverse clinics, and discuss challenges and progress in the implementation of KBP for brachytherapy treatment planning. Additionally, we briefly discuss secondary applications of KBP for cervical cancer. The emerging picture from these studies indicates several exciting opportunities for increasing the utilization of KBP in day-to-day cervical cancer radiotherapy.
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Affiliation(s)
- Tahir I Yusufaly
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA
| | - Sandra M Meyers
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA
| | - Kevin L Moore
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA.
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22
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Williamson CW, Liu HC, Mayadev J, Mell LK. Advances in External Beam Radiation Therapy and Brachytherapy for Cervical Cancer. Clin Oncol (R Coll Radiol) 2021; 33:567-578. [PMID: 34266728 DOI: 10.1016/j.clon.2021.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/04/2021] [Accepted: 06/28/2021] [Indexed: 11/18/2022]
Abstract
The standard of care for the definitive treatment of locoregionally advanced cervical cancer is external beam radiation therapy (EBRT) with concurrent chemotherapy followed by a brachytherapy boost. Historically, EBRT was delivered via a two-dimensional technique based primarily on bony landmarks. This gave way to three-dimensional conformal radiation therapy, which allows for dose calculation and adjustment based on individual tumour and patient anatomy. Further technological advances have established intensity-modulated radiation therapy (IMRT) as a standard treatment modality, given the ability to maintain tumoricidal doses to target volumes while reducing unwanted radiation dose to nearby critical structures, thereby reducing toxicity. Routine image guidance allows for increased confidence in patient alignment prior to treatment, and the ability to visualise the daily position of the targets and organs at risk has been instrumental in allowing safe reductions in treated volumes. Additional EBRT technologies, including proton therapy and stereotactic body radiation therapy, may further improve the therapeutic index. In the realm of brachytherapy, a shift from point-based dose planning to image-guided brachytherapy has been associated with improved local control and reduced toxicity, with additional refinement ongoing. Here we will discuss these advances, the supporting data and future directions.
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Affiliation(s)
- C W Williamson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - H C Liu
- La Jolla Center for Precision Radiation Medicine, La Jolla, California, USA
| | - J Mayadev
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - L K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA; La Jolla Center for Precision Radiation Medicine, La Jolla, California, USA.
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23
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Glaser SM, Mohindra P, Mahantshetty U, Beriwal S. Complications of intracavitary brachytherapy for gynecologic cancers and their management: A comprehensive review. Brachytherapy 2021; 20:984-994. [PMID: 33478905 DOI: 10.1016/j.brachy.2020.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Intracavitary gynecologic brachytherapy in the form of tandem-based brachytherapy and vaginal cylinder-based brachytherapy represents a fundamental component of the treatment of women with cervical or uterine cancer due to the ability to deliver a therapeutic dose of radiation with sharp dose falloff. This results in highly effective treatment in terms of oncologic outcomes with an overall favorable toxicity profile. Still, complications and side effects of brachytherapy do exist. While advances in brachytherapy techniques have led to a significant decrease in the rates of toxicity, a thorough understanding of the potential complications is crucial to ensuring optimal outcomes for women with gynecologic cancer undergoing brachytherapy. Use of equivalent dose at 2 Gy per fraction (EQD2) models has allowed incorporation of external beam radiotherapy dose to the brachytherapy dose leading to development of consolidated dose constraints for organs-at-risk in the modern era. This manuscript offers a comprehensive review of potential complications associated with intracavitary brachytherapy for gynecologic cancer including predictive factors, mitigation tactics, and management strategies.
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Affiliation(s)
- Scott M Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA.
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
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24
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Radiation-Induced Insufficiency Fractures After Pelvic Irradiation for Gynecologic Malignancies: A Systematic Review. Int J Radiat Oncol Biol Phys 2020; 108:620-634. [DOI: 10.1016/j.ijrobp.2020.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/15/2022]
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Mir R, Dragan AD, Mistry HB, Tsang YM, Padhani AR, Hoskin P. Sacral Insufficiency Fracture Following Pelvic Radiotherapy in Gynaecological Malignancies: Development of a Predictive Model. Clin Oncol (R Coll Radiol) 2020; 33:e101-e109. [PMID: 33127236 DOI: 10.1016/j.clon.2020.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/27/2020] [Accepted: 10/14/2020] [Indexed: 12/25/2022]
Abstract
AIMS To investigate the time-to-event and the evolution of sacral insufficiency fractures in gynaecological patients receiving pelvic external beam radiotherapy (EBRT) in relation to dosimetric and imaging parameters across a spectrum of radiotherapy delivery techniques, and to develop a predictive model with a clinical nomogram to identify those at risk of sacral insufficiency fracture. MATERIALS AND METHODS Patients who received radical or adjuvant pelvic EBRT for gynaecological malignancy between 2014 and 2019 were identified. The data collected were: demographics and clinical details; radiotherapy planning data: dose, fractionation, technique (fixed-field intensity-modulated radiotherapy, adaptive arc, and non-adaptive arc), 60 Gy simultaneous integrated boost. Each plan was examined to determine the sacral dose in 5%/Gy3 increments. Follow-up magnetic resonance scans were reviewed for insufficiency fractures, defined as linear low T1-weighted signal intensity with a high short-T1 inversion recovery (STIR) signal. The site of insufficiency fracture was recreated on the planning computed tomography, the dose to insufficiency fracture contours was recorded and insufficiency fractures were determined as healed with resolution of high STIR signal. Univariable analysis was conducted of the clinical variables. The area under the receiver operator characteristic curve and odds ratio of the risk prediction model with 95% confidence interval are reported with a nomogram for use in clinical practice. RESULTS 115 patients were identified; the median imaging follow-up was 12 months (2-47). 37.4% developed sacral insufficiency fractures; 93.0% were detected within 12 months of EBRT. At the final radiological follow-up, 83.7% of insufficiency fractures remained active. The radiotherapy delivery technique was not associated with insufficiency fracture after adjusting for patient age (P = 0.115). The location of the 60 Gy simultaneous integrated boost planning target volume did not impact upon the site of insufficiency fracture or the dose received by the insufficiency fracture sites. Age and V40Gy3 are predictors for insufficiency fracture and form the clinical risk model (receiver operator characteristic 0.72). CONCLUSIONS Age and V40Gy3 predict sacral insufficiency fractures; future work should focus on optimising radiotherapy planning with adoption of a bone-sparing planning approach for those patients at high risk of insufficiency fracture.
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Affiliation(s)
- R Mir
- Mount Vernon Cancer Centre, Northwood, UK; National Radiotherapy Trials Quality Assurance (RTTQA) Group, UK
| | - A D Dragan
- Paul Strickland Scanner Centre, Northwood, UK
| | - H B Mistry
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Division of Pharmacy, University of Manchester, Manchester, UK
| | - Y M Tsang
- Mount Vernon Cancer Centre, Northwood, UK
| | - A R Padhani
- Paul Strickland Scanner Centre, Northwood, UK
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, UK; National Radiotherapy Trials Quality Assurance (RTTQA) Group, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK.
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Desideri I, Salvestrini V, Livi L. Recent advances in de-intensification of radiotherapy in elderly cancer patients. F1000Res 2020; 9. [PMID: 32518630 PMCID: PMC7255897 DOI: 10.12688/f1000research.21151.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer in the elderly remains an evolving issue and a health challenge. Several improvements in the radiotherapy field allow the delivery of higher doses/fractions with a safe toxicity profile, permitting the reduction of radiation treatment protocols in the elderly. Regarding breast, prostate, and lung cancer, the under-representation of older patients in clinical trials limits the extension of treatment recommendations to elderly patients in routine clinical practice. Among the feasible alternatives to standard whole breast radiotherapy (WBRT) in older patients are shorter courses using higher hypofractionation (HF) and accelerated partial breast irradiation (APBI). The boost continues to be used in women at high risk of local recurrence but is less widely accepted for women at lower risk and patients over 70 years of age. Regarding prostate cancer, there are no published studies with a focus on the elderly. Current management decisions are based on life expectancy and geriatric assessment. Regimens of HF and ultra-HF protocols are feasible strategies for older patients. Several prospective non-randomized studies have documented the safe delivery of ultra-HF for patients with localized prostate cancer, and multiple phase III trials and meta-analyses have confirmed that the HF regimen should be offered with similar acute toxicity regardless of patient age and comorbidity. A recent pooled analysis from two randomized trials comparing surgery to stereotactic body radiation therapy (SBRT) in older adult patients with early stage non-small cell lung cancer did show comparable outcomes between surgery and SBRT. Elderly cancer patients are significantly under-represented in all clinical trials. Thus, the inclusion of older patients in clinical studies should be strongly encouraged to strengthen the evidence base for this age group. We suggest that the creation of oncogeriatric coordination units may promote individualized care protocols, avoid overtreatment with aggressive and unrecommended therapies, and support de-escalating treatment in elderly cancer patients.
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Affiliation(s)
- Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| | - Viola Salvestrini
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
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Phase 1 Trial of Concurrent Gemcitabine and Cisplatin with Image Guided Intensity Modulated Radiation Therapy for Locoregionally Advanced Cervical Carcinoma. Int J Radiat Oncol Biol Phys 2020; 107:964-973. [PMID: 32334034 DOI: 10.1016/j.ijrobp.2020.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE The use of concurrent doublet chemotherapy with radiation for locoregionally advanced cervical cancer (LACC) is limited by gastrointestinal and hematologic toxicity. By reducing radiation dose to bowel and bone marrow, image guided intensity modulated radiation therapy (IG-IMRT) may improve chemotherapy tolerance. The goal of this study was to determine whether IG-IMRT could lead to improved tolerance to concurrent cisplatin and gemcitabine for LACC. METHODS AND MATERIALS We conducted an open-label, nonrandomized, prospective phase 1 dose escalation trial at a tertiary academic cancer center (ClinicalTrials.gov identifier: NCT01554410). We enrolled patients with stage IB-IVA cervical cancer, with either an intact cervix or posthysterectomy with residual/recurrent pelvic or paraortic nodal involvement, undergoing radical pelvic or extended field chemoradiation therapy. Treatment consisted of chemoradiation with IG-IMRT (45-47.6 Gy, 25-28 fractions to the pelvis ± paraortic nodes with simultaneous nodal boost to 53.2-59.4 Gy, 28 fractions) plus 5 cycles of concurrent weekly cisplatin 40 mg/m2 with escalating doses of gemcitabine (50, 75, 100, or 125 mg/m2). Cohorts were separated preregistration according to whether the patient received pelvic or extended field IG-IMRT and whether gemcitabine followed (CG) or preceded (GC) cisplatin delivery. Dose-limiting toxicity (DLT) events were monitored up to 30 days after chemoradiation therapy. The primary endpoint was maximum tolerated dose (MTD) resulting in DLT probability ≤20%. RESULTS Between February 2011 and June 2019, 35 patients were registered. Overall, 7 patients (20.0%) experienced DLTs. For the pelvic field cohort, the estimated MTD was 100 mg/m2 with GC sequencing, which is higher than the previously reported MTD for this regimen. The extended field cohort was closed after 2 of 3 patients experienced a DLT at the first dose level. CONCLUSIONS IG-IMRT can permit higher doses of concurrent gemcitabine with cisplatin and pelvic radiation for LACC. However, acute toxicity remains a factor with this regimen, depending on radiation volume and chemotherapy sequencing.
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To Fracture Not—Sustained Benefits of Intensity Modulated Radiation Therapy (IMRT) in Pelvic Malignancies. Int J Radiat Oncol Biol Phys 2020; 106:493-495. [DOI: 10.1016/j.ijrobp.2019.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 11/18/2022]
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